Immuno-mediated Oral Diseases Flashcards
What are some LOCALISED immunological oral diseases?
- Apthous ulcers
- Lichen planus
- OFG
- Lupus erythematosus (CDLE)
What are some SYSTEMIC immunological diseases with oral effects?
- Erythema multiforme
- Pemphigus
- Pemphigoid
- Lupus erythematosus
- Systemic sclerosis
- Sjogren’s syndrome
What are the causes of recurrent oral ulcerations?
- Trauma
- Medication
- Apthous ulcers
- Lichen planus
- Viral reactivation (herpes)
- Vesicullobullous diseases (pehmigus, phemphigoid, angina bullosa haemorrhagica)
What are the types of recurrent apthous stomatitis?
- Major
- Minor
- Herpetiform
What are the characteristics of MINOR recurrent apthous ulcers?
- <10mm
- Oval - RED HALO, YELLOW BASE
- 1-20 per crop
- Affects mainly non-keratinising mucosa
- Heals 1-2 weeks, w/o scarring
What are the characteristics of MAJOR recurrent apthous ulcers?
- > 10mm
- Oval
- <5 per crop
- Affects both keratinising/ non-keratinising mucosa
- Heals 6-12 weeks, usually scars
What are the characteristics of HERPETIFORM recurrent apthous ulcers?
- <5mm
- Oval - often fuse into large areas of ulcerations
- 1-200 per crop
- Affects non-keratinising mucosa
- Heal 1-2 weeks, w/o scarring
What is Behcet’s Syndrome?
- Rare, blood vessel inflammatory condition
- Affects = eyes, joints (arthritis), neurological, GI
- Ulcerations = oral, genital and skin
What are the causes of recurrent APTHAE ulcerations?
Host
- Genetic
- Deficiencies (iron, folate, vit b12)
- Systemic diseases (menorrhagia, chronic GI bleeding, dietary malabsorption, ulcerative colitis)
- Endocrine disease (?progesterone)
- Immunity
Environmental
- Trauma
- Allergy
What drug therapies may be used for recurrent apthae ulcers?
TOPICAL immune-modulating (STEROIDS)
- Betamethasone mw (0.5mg 3x daily)
- Beclometasone (brown) inhaler (50ug puffs 3x daily)
SYSTEMIC immune-modulating
- Systemic steroid (prednisolone)
- DMARD (azathioprine)
What are Wickham’s striae and which condition is this seen in?
- White lines seen in papules of LICHEN PLANUS
What are the SEVEN types of lichen planus?
- Reticular
- Papular
- Plaque
- Atrophic
- Erosive
- Bullous
- Desquamative gingivitis
Describe the histology of lichen planus
- Keratosis
- Atrophic/ hyperplastic epithelium
- Epitheliotropism (affinity for epithelium; lymphocyte presence)
- Basal cell liquefaction/ degeneration
- ‘Blue/ hugging band’ of lymphocytes following fossae of Rete pegs
What are the treatment options for lichen planus?
ASYMTOMATIC
- Observe (6 months, repeat)
- CHX mw (ensure OH is good)
SYMPTOMATIC
- Remove cause/ SLS-free toothpaste
- Topical steroids
- Systemic steroids
- Systemic immunomodulation
BOTH
- Betamethasone mw (tablet -> water)
When should a biopsy be taken in a patient with lichen planus?
- EVERYONE = SYMPTOMATIC/EROSIVE type
- SMOKERS = ALL TYPES
What is erythema multiforme?
- Skin condition with unknown cause (most likley immune-complex?)
- Erythematous lesions seen
- Can affect lips and anterior part of mouth
What is the management for oral manifestations of erythema multiforme?
- Urgent medical therapy = systemic steroids, systemic aciclovir (common end stage of blistering is HSV expression)
- Encourage fluid uptake (may require IV fluids)
- Encourage analgesia
- IF recurrent = consider daily prophylactic aciclovir and allergy testing (benzoates)
Where are desmosomes found?
WITHIN epithelium layer (simple/ stratified squamous)
Where are hemidesmosomes found?
BETWEEN epithelium and laminar propria layer
What are the types of immunofluorescence testing?
- DIRECT (biopsy to prove antibody attaches to tissues)
- INDIRECT (blood sample for antibody)
What is pemphigoid?
- Vesiculobullous disease (blistering disease)
- Antibody attack of SUB-epithelial layers (hemidesmosomes)
- Thick-walled blisters are seen, filled with blood
Relatively common
What types of pemphigoid are there?
- Bullous pemphigoid (skin)
- Mucous membrane pemphigoid (oral)
Describe the histopathology of pemphigoid
- Sub-basal (/epithelial) split, vesicle
Describe the appearance of direct immunofluorescence of pemphigoid
- Linear distribution seen (glowing) sub-basal (/epithelial)
How is pemphigoid managed?
- Immunosuppressants (steroids, immunomodulating drugs)
What is pemphigus?
- Vesculobullous disease (blistering disease)
- Antibody attack of INTRA-epithelial layer (desmosomes)
- Thin-walled blisters seen, filled with serous fluid (rarely seen intact)
S = superficial, serous, steroids
Describe the histopathology of pemphigus
Blister formed entirely WITHIN epithelial layer
Describe the appearance of direct immunofluorescence of pemphigus
- “Basket weave” appearance (glowing seen AROUND epithelial cells)
What is angina haemorrhagica bullosa?
- Blood blisters in absence of trauma
- Isolate nature, rapid healing and rare occurrence
- Commonly seen in soft palate
- Commonly seen in long-term steroid-using asthmatics
What investigations should be considered for suspected angina haemorrhagica bullosa?
- Platelet count
- Coag screen
- LFT
- Blood glucose
- Immunofluorescence
How is angina haemorrhagica bullosa managed?
Advise pt to de-roof blister with something sharp (otherwise it will keep filling with blood and grow)
What is epidermolysis bullosa?
CT disease which causes blistering of skin and mucous membrane
Mild - severe (death at birth)
